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Metastatic lesion to the cervico-thoracic junction


Introduction

The cervical spine is the least common site affected by metastatic tumors of the vertebral column, but despite this, the presence of space occupying lesions in this region may cause severe symptomatology and morbidity. Additional involvement of the upper thoracic segment often leads to instability. Metastatic tumors are more common than primary tumors in this region. The surgical management of metastatic lesions to the cervico-thoracic junction (CTJ) is widely variable among providers and institutions. The anatomy of the upper thoracic spine presents a challenge for anterior access, often requiring median sternotomy for complete exposure and added morbidity. The biomechanics of the CTJ are also dependent on the posterior tension band provided by the paraspinal musculature and ligamentous complex, which is often disrupted by tumor and must be removed in order to complete the resection. Tumor localization at the lower cervical segment is more frequent, and lesions on this region are related to a higher risk of instability due to its mobility. Aggressive surgical resection of metastatic lesions in this area may confer a survival benefit; however, it can have considerable morbidity. Moreover, surgical resection has shown superiority in relieving compression, controlling pain, and improving function. The most common approach for metastatic lesions involving the cervico-thoracic region involves posterior or posterolateral resection and decompression involving laminectomy and supplemented by posterior fixation to avoid instability. An exclusive anterior approach is typically not sufficient to achieve stabilization in most cases. In this chapter, we present a case of a 79-year-old man who began complaining of neck pain after radiation for thyroid cancer and has a lesion involving the cervico-thoracic region.

Example case

  • Chief complaint: neck pain and upper and lower extremity weakness

  • History of present illness: This is a 79-year-old male patient with a history of thyroid cancer status post thyroidectomy and radiation who presented with a 3-week history of neck pain and rapidly progressive weakness. He was unable to ambulate or feed and dress himself. He was independent with his activities of daily living until 3 weeks ago before consultation. He also had new urinary incontinence. The patient underwent a cervical magnetic resonance image that showed a space occupying lesion at the level of the cervico-thoracic junction ( Figs. 55.1–55.2 ).

    Fig. 55.1, Preoperative magnetic resonance images. (A) Axial T1 with contrast demonstrating an enhancing heterogeneous lesion extending from the posterior aspect of the vertebral arch anteriorly and laterally more on the right side. (B) Sagittal T1 demonstrating an abnormal hypointense lesion spanning the entire C7 spinous process. (C) Sagittal T2 demonstrating a hyperintense lesion at the C7 spinous process, extending anteriorly and compressing the spinal cord. There is also an extensive syrinx extending from C3 to T2. There appears to be an extradural mass right behind the C5 vertebral body.

    Fig. 55.2, Preoperative lateral cervico-throacic spine x-rays. Lateral view demonstrating erosion of the C7 posterior elements by a soft tissue mass. Vertebral body heights are maintained. Anterolisthesis of C4 on C5 and C5 on C6. Multilevel degenerative disc disease and facet osteoarthritis are also seen.

  • Medications: aspirin 325 mg

  • Allergies: no known drug allergies

  • Past medical and surgical history: thyroid cancer, previous transient ischemic attacks, coronary artery disease, thyroidectomy

  • Family history: none

  • Social history: none

  • Physical examination: awake, alert, and oriented to person, place, and time; cranial nerves II–XII intact; bilateral deltoids/triceps/biceps 3/5; interossei 2/5; iliopsoas 3/5; knee flexion/knee extension/dorsi, and plantar flexion 2/5

  • Reflexes: 3+ in bilateral biceps/triceps/brachioradialis with positive Hoffman; 3+ in bilateral patella/ankle; bilateral Babinski; sensation decreased to light touch

  • Anas Abdallah, MD

  • Neurosurgery

  • Osmaniye State Hospital

  • Osmaniye, Turkey

  • Benjamin D. Elder, MD, PhD

  • Neurosurgery

  • Mayo Clinic

  • Rochester, Minnesota, United States

  • Aron Lazary, MD, PhD

  • Orthopaedic Surgery

  • Buda Health Center

  • Semmelweis University

  • Budapest, Hungary

  • Praveen Mummaneni, MD

  • Brenton Pennicooke, MD

  • Neurosurgery

  • University of California at San Francisco

  • San Francisco, California, United States

Preoperative
Additional tests requested

  • CT brain and complete spine

  • CT cervical spine

  • Cervical x-rays

  • PET

  • Oncology evaluation

  • Anesthesia evaluation

  • CT-guided biopsy of C7 spinous process

  • CT neck with contrast

  • CT chest/abdomen/pelvis

  • Otolaryngology evaluation

  • Possible preoperative embolization

CT C-spine

  • CTA C-spine

  • PET

  • Preoperative embolization

Surgical approach selected If survival > 12 weeks, C7 laminectomy and excisional biopsy Pending pathology, C5 corpectomy and posterior C3-T1 laminectomy and C2-T4 instrumented fusion C6-T1 decompression and C5-T3 posterior fusion C3-T2 posterior fusion and C3-T1 laminectomy
Goal of surgery Diagnosis, decompression of spinal cord Decompress spinal cord and nerve roots, stabilize spine Decompress spinal cord, tumor debulking, stabilize spine Decompress spinal cord
Perioperative
Positioning Prone with Mayfield pins Stage 1: supine with gel donut and Garner-Wells tongs Stage 2: prone on Jackson table with pins Prone, with pins Prone on Jackson table, with Mayfield pins
Surgical equipment

  • IOM

  • Fluoroscopy

  • Surgical microscope

  • Otolaryngology exposure

  • Fluoroscopy

  • IOM (MEP, SSEP)

  • Surgical microscope

  • Bone scalpel

  • Ultrasound

  • O-arm

  • Fluoroscopy

  • Surgical navigation

  • IOM (MEP/SSEP/EMG)

  • Fluoroscopy

  • Surgical navigation

  • Intraoperative CT

Medications Steroids, maintain MAP Steroids Steroids None
Anatomical considerations Spinal cord, nerve roots, dura

  • Stage 1: carotid sheath, recurrent laryngeal nerve, esophagus, vertebral arteries

  • Stage 2: vertebral arteries, spinal cord, nerve roots

Dorsal muscles, lamina, spinal canal, lateral masses Spinal cord, vertebral arteries
Complications feared with approach chosen Instability, motor deficit, CSF leak Worsening spinal cord compression, paralysis Spinal cord injury
Intraoperative
Anesthesia General General General General
Exposure C7 C2-T4 C4-T3 C3-T2
Levels decompressed C7 C3-T1 C6-T1 C3-T1
Levels fused None C2-T4 C4-T3 C3-T2
Surgical narrative Position prone with head in Mayfield pins, slight flexion, vertical midline posterior incision from C6-T1, central splitting at midline down C7 spinous process, subperiosteal dissection of paraspinal muscles, confirm C7 level with fluoroscopy, bilateral C7 laminectomy with high-speed drill and Kerrison rongeurs, open along lamina-facet interface down to ligamentum flavum, ligament cut transversely at upper and lower ends, lamina elevated, medial portions of facet are removed to decompress existing nerve roots, biopsy specimen, layered closure with drain Stage 1: Position supine on flat Jackson table with gel axillary roll transversely across shoulders with 10 lb of traction, localization with fluoroscopy, incision over C5 vertebral body in neck crease, transverse neck incision contralateral to area of worst compression, mobilize esophagus medially and carotid sheath laterally, place distraction pin in vertebral body for localizing x-ray, mobilize longus colli off vertebral bodies, place retractor system and 144 mm distraction pins in C4 and C6, complete C4-5 and C5-6 discectomies, remove C5 vertebral body with rongeurs taking care to not laterally injury vertebral arteries, open PLL and resect ventral epidural tumor, size and place titanium mesh cage packed with morcellized allograft, place anterior plate from C4-C6, obtain final x-rays, leave drain in retropharyngeal space, flip for stage 2Stage 2: Position prone on Jackson table with head in neutral position with pins, Position prone, standard posterior midline approach from C4-T3, place bilateral lateral mass screws from C4-C6 and pedicle screws from T1-T3 under navigation if available, cement T3 if bone quality poor, remove tumor-involved lamina from C6-T1, laminectomy C6-T1 and C7 foramens, lock screws with transient rods, layered closure with two deep drains Position prone, lateral x-ray to plan incision, expose C3-T2, place navigation array on T2 spinous process, intraoperative CT and register with navigation system, plan/decorticate entry points/place T1-T2 pedicle screws with navigation, decorticate entry points/place C3-6 lateral mass screws, C3-T1 laminectomy and resection of posterior aspect of tumor, run MEP after completing laminectomies, place rods connecting screws from C3-T2, obtain intraoperative CT to confirm hardware location, final tighten caps, place allograft along decorticated lateral masses and transverse processes, layered wound closure with subfascial drains

  • expose from C2 to T4 with preservation of C1-2 muscle/ligament insertion and distal ligaments, localizing x-ray, cannulate 14–16 mm tracts for lateral mass screws from C3-6 using normal anatomy, cannulate and place T1-4 pedicle screws, complete laminectomy from inferior aspect of C3 to superior aspect of T1, intraoperative ultrasound to confirm adequate decompression of spinal cord, cannulate C2 pedicles using anatomical landmarks and place C2 pedicle screws, intraoperative O-arm spin to confirm adequate screw position, place from C2-T4 tapered titanium rods, decortication of posterior elements, place morcellized allograft, place subfascial drains, layered closure

Complication avoidance Minimize opening to one level, decompress nerve roots Preoperative embolization increase neck extension with gel axillary roll, approach contralateral to area of worse compression, distraction pin in vertebral body for localization, preserve C1-2 muscle/ligament insertion and distal ligaments, extend fusion to T4 because of T2 involvement, intraoperative ultrasound to assess decompression, O-arm to confirm screw placement, tapered titanium rods Surgical navigation if available, cement T3 if bone quality poor Preoperative embolization, debulk posterior aspect of tumor, repeat CT to confirm hardware location
Postoperative
Admission ICU ICU ICU ICU
Postoperative complications feared Hematoma, CSF leak, nerve palsy, neck pain, neuropathic pain, cervical instability, vascular injury, delayed wound recovery Swallowing dysfunction, hoarseness, neck hematoma, C5 palsy Wound infection C5 palsy
Anticipated length of stay 2 days 4–5 days 5–7 days 5 days
Follow-up testing

  • CT cervical spine within 24 hours of surgery

  • Oncology evaluation

  • Medical oncology evaluation

  • Radiation oncology evaluation

  • AP/lateral x-rays 6 weeks, 3 months, 6 months, 1 year after surgery

  • C-T spine x-ray after drain removal

  • Oncology evaluation

  • AP and lateral C-spine x-ray prior to discharge

  • Radiation oncology evaluation

  • Radiation therapy 3 weeks after surgery

Bracing Rigid neck collar for 3–4 weeks Miami J with thoracic extension when out of bed None Miami J for 6 weeks
Follow-up visits 2 weeks, 6 weeks, every 3 months after surgery 2 weeks, 6 weeks, 3 months, 6 months, 1 year after surgery 3 months, 6 months, 12 months, 24 months after surgery 3 weeks after surgery
AP , Anteroposterior; CSF , cerebrospinal fluid; CT , computed tomography; CTA , computed tomography angiography; DEXA , dual-energy x-ray absorptiometry; ICU , intensive care unit; IOM , intraoperative monitoring; MAP , mean arterial pressure; MEP , motor evoked potentials; PET , positron emission tomography; PLL , posterior longitudinal ligament; SSEP , somatosensory evoked potentials

Differential diagnosis

  • ▪

    Degenerative cervical or thoracic stenosis

  • ▪

    Herniated cervical or thoracic disc

  • ▪

    Transverse myelitis

  • ▪

    Spinal cord infarction

  • ▪

    Metastatic spinal disease

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